Perceptions of chest pain differ by race

Multicultural presentation of chest pain at an emergency department in Australia

OBJECTIVE

To investigate differences in presenting patient characteristics, investigation, management and related outcomes between culturally and linguistically diverse (CALD) and non-CALD chest pain (CP) patients presenting to the ED.

METHODS

A cohort study of 258 patients was enrolled on presentation to Liverpool Hospital ED with a complaint of CP over a 2-week period. Main outcomes included frequency and timeliness of diagnostic and radiological investigations, medication administered and ED length of stay. Administrative and clinical data were extracted and linked from Cerner EMR FirstNet®, PowerChart® and paper records.

RESULTS

There were 155 (60%) CALD and 103 (40%) non-CALD patients. CALD patients were older by 10 years (95% CI 4, 15; P < 0.0001). There were no significant differences in the number of pathology and imaging investigations carried out in each group, and similarly there were no significant differences in the number of patients administered analgesia or cardiac-specific medications. Neither group differed in their ED length of stay (median 280 vs 259.5 min; P = 0.79) or hospital admission rate (median 56% vs 55%, P = 0.8).

CONCLUSION

Both CALD and non-CALD ED CP patients had similar test ordering, medication administration and clinical outcomes, but this was in the context of CALD patients being 10 years older together with a small study sample size. A larger cohort, matched for age, would provide further insights into potentially important differences.

Acute coronary syndromes presentations and care outcomes in white, South Asian and Chinese patients: a cohort study

OBJECTIVES

Successful treatment of acute coronary syndrome (ACS) relies on its rapid recognition. It is unclear whether the accepted presentation of chest pain applies to different ethnic groups. We thus examined potential ethnic variations in ACS symptoms and clinical care outcomes in white, South Asian and Chinese patients.

DESIGN

Cross-sectional survey.

SETTING

Participants were hospitalised at 1 of 12 Canadian centres across four provinces.

PARTICIPANTS

1334 patients with ACS (630 white; 488 South Asian; 216 Chinese).

MAIN OUTCOME MEASURES

ACS presentation symptoms (classic/typical midsternal pain/discomfort with or without radiation to the left neck, shoulder or arm) were assessed by self-report. Clinical care outcomes (time to emergency room [ER] presentation, cardiac catheterisation; receipt of cardiac catheterisation, percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) were obtained by health record audit.

RESULTS

The mean age of the sample was 62 years and 30% had ST-elevation myocardial infarction (STEMI). The most common presenting symptom was midsternal pain/discomfort of any intensity regardless of ethnic status. Yet, a substantial proportion of patients reported atypical symptoms (33% white, 19% South Asian, 20% Chinese; p<0.006). After adjustment for age, sex, education, current smoking, extent of coronary artery disease, presence of diabetes or chronic kidney disease and STEMI vs non-STEMI/unstable angina, South Asians were more likely to present with at least moderate intensity midsternal pain/discomfort (adjusted OR [AOR] 1.44; 95% CI 1.05 to 1.98), whereas Chinese were less likely to present with radiating symptoms (AOR 0.53; 95% CI 0.38 to 0.74) compared with whites. South Asians with atypical pain (relative to those with midsternal pain/discomfort) took significantly longer to present to the ER (p=0.037), and were less likely to receive PCI (p=0.008) or CABG (p=0.041).

CONCLUSIONS

Atypical presentations were associated with greater delays in arrival to the emergency department and reduced invasive cardiovascular care in South Asians.

A review of racial disparities in transcatheter aortic valve replacement (TAVR): accessibility, referrals and implantation

Racial disparities in transcatheter aortic valve replacement (TAVR) implantation results from several factors, including socioeconomic disparities, inherent biases in healthcare provision, fewer referrals to specialists and language barriers in some minority populations. In this review article, we discuss the current data on the racial disparities in TAVR, explore the prevalence of aortic stenosis in different demographics in the United States and we proffer practical solutions to these problems.

Sex, Race, and Socioeconomic Disparities in Patients With Aortic Stenosis (from a Nationwide Inpatient Sample)

Aortic stenosis (AS) is the third most prevalent cardiovascular disease following hypertension and coronary artery disease. The primary objective of this cross-sectional study is to examine gender, racial, and socioeconomic disparities in AS-related health care utilization in patients aged ≥50 years using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. AS was identified among inpatient discharges with International Classification of Diseases, Ninth Revision, Clinical Modification, code 424.1. Using stratum-specific weighted totals, means, proportions, and regression models, we examined time trends and disparities for inhospital AS prevalence according to gender, race, and income over the 2002 to 2012 period, predictors of AS (gender, race, income, age, health insurance, co-morbidities, and hospital-level characteristics), and AS's role as a predictor of inhospital death, length of stay, and total charges. Inhospital AS prevalence increased from 2.10% in 2002 to 2.37% in 2012, with similar trends observed within gender, race, and income strata. Women were less likely to have AS compared with men (adjusted odds ratio [ORadj] 0.84; 95% confidence interval [CI] 0.83 to 0.86). Blacks (ORadj 0.68; 95% CI 0.66 to 0.71), Hispanics (ORadj 0.79; 95% CI 0.76 to 0.84), and Asians/Pacific Islanders (ORadj 0.68; 95% CI 0.64 to 0.74) were less likely than whites to have AS diagnosis that was directly associated with income. AS was inversely related to inhospital death but positively linked to total charges overall and longer hospital stays among men, whites, and middle-income patients. However, shorter stays with AS were observed among blacks. In conclusion, among older inpatients, AS prevalence was ∼2% and was higher among males, whites, and higher income groups. Although inhospital death was lower and total charges were higher in AS, length of stay's association with AS varied by gender, race, and income.

Disparities in patients presenting to the emergency department with potential acute coronary syndrome: it matters if you are Black or White

OBJECTIVES

To explore disparities between non-Hispanic Blacks and non-Hispanic Whites presenting to the emergency department (ED) with potential acute coronary syndrome (ACS).

BACKGROUND

Individuals with fewer resources have worse health outcomes and these individuals are disproportionately those of color.

METHODS

This prospective study enrolled 663 patients in four EDs. Clinical presentation, treatment, and patient-reported outcome variables were measured at baseline, 1, and 6 months.

RESULTS

Blacks with confirmed ACS were younger; had lower income; less education; more risk factors; more symptoms, and longer prehospital delay at presentation compared to Whites. Blacks experiencing palpitations, unusual fatigue, and chest pain were more than 3 times as likely as Whites to have ACS confirmed. Blacks with ACS had more clinic visits and more symptoms 1 month following discharge.

CONCLUSIONS

Significant racial disparities remain in clinical presentation and outcomes for Blacks compared to Whites presenting to the ED with symptoms suggestive of ACS.

Anginal symptoms, coronary artery disease, and adverse outcomes in Black and White women: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study

BACKGROUND

Black women are less likely to be evaluated and treated for anginal symptoms, despite a higher premature cardiac mortality rate compared to white women. Our objective was to compare angina symptoms in black versus white women regarding (1) angina symptoms characterization; (2) relationship with obstructive coronary artery disease (CAD); and (3) relationship with subsequent mortality.

METHODS

A cohort of 466 women (69 black and 397 white) undergoing coronary angiography for suspected ischemia and without prior history of CAD completed symptom checklists. Four symptom clusters (CHEST, UPPER, STOMACH, and TYPICAL TRIGGERS) were derived by factor analysis. All angiograms were analyzed by core lab. Mortality data over 10 years were obtained from National Death Index.

RESULTS

(1) Black women had lower mean CHEST cluster scores (0.60±0.30 vs. 0.73±30, p=0.002), but higher STOMACH scores (0.41±0.25 vs. 0.30±0.25, p=0.011) than white women. (2) Prevalence and severity of CAD did not differ in black and white women and was not predicted by symptom cluster scores. (3) All-cause mortality rates were 24.9% in blacks versus 14.5% in whites, p=0.007; and cardiovascular mortality 22.5% vs.8.8%, p=0.001. Symptom clusters were not predictive of adverse events in white women. However, black women with a low TYPICAL score had significantly higher mortality compared to those with a high TYPICAL score (43% vs. 10%, p=0.006).

CONCLUSIONS

Among women undergoing coronary angiography, black women report fewer chest-related and more stomach-related symptoms, regardless of presence or severity of CAD, and these racial symptom presentation differences are linked with the more adverse prognosis observed in the black women. Atypical symptom presentation may be a barrier to appropriate and timely diagnosis and treatment and contribute to poorer outcomes for black women.

Management of noncardiac chest pain in women

Noncardiac chest pain (NCCP) is very prevalent in the community. Although mortality remains low, morbidity and the financial implications are high. Women, especially those of middle age, should be thoroughly investigated as per current guidelines for coronary artery disease before labeling their chest pain as NCCP. Gastroesophageal reflux disease is the most common cause of NCCP; however other esophageal pathology including esophageal hypersensitivity, neuromuscular disease and eosinophilic esophagitis may also cause NCCP. Proton pump inhibitors are commonly used initially to manage NCCP, although patients who do not respond to this therapy require further investigation and differing treatment regimes. This article will focus on current knowledge regarding GI tract-related NCCP management strategies.

Acute coronary syndrome: factors affecting time to arrival in a diverse urban setting

This study seeks to better understand how individuals of different cultural/ethnic backgrounds in an urban setting assess the signs and symptoms of Acute Coronary Syndrome (ACS) and the ensuing decision to take urgent action. Few studies exist which examine these differences and enhance understanding of how to address these differences and, ultimately, reduce morbidity and mortality from ACS. Face-to-face interviews were conducted with a convenience sample of urban patients of different cultural and socioeconomic backgrounds regarding their actions upon recognition of ACS signs and symptoms. Patients (423) with presumed or diagnosed ACS were interviewed within 12 h of arrival at the urban emergency rooms. Among the different cultural groups, Haitians delayed the longest (median) from symptom onset to hospital arrival (8.24 h), followed by Caribbeans (7.83 h), African Americans (6.62 h) and Hispanics (6.00 h). Although these delay intervals were not statistically significant across groups, each racial/ethnic group sought care well beyond the recommended time period of 3 h after initial recognition of ACS signs and symptoms. Among all the cultural groups, the two key factors motivating early arrival were being employed and taking positive actions. ACS symptom perception by different cultural groups appears to play an important role in the decision to seek emergency treatment. This is an area that has not been widely studied among or within different cultural/ethnic groups. As such, further research is needed to delineate these concepts and actions and to provide opportunities for appropriate education.

Gender differences on chest pain perception associated with acute myocardial infarction in Chinese patients: a questionnaire survey

AIMS

To investigate gender differences in chest pain perception among Chinese patients with acute myocardial infarction.

BACKGROUND

Thrombolytic therapy is beneficial to outcomes of acute myocardial infarction if administered within 12 hours from the onset of chest pain. However, cardiac symptom interpretation may impact time of presentation to hospital. Differences in cardiac symptom reports by gender partly explain misdiagnoses and delays in treatment, particularly among women. Whether, such trends apply to Chinese patients with myocardial infarction is unknown.

DESIGN

A descriptive prospective study.

METHODS

Using questionnaires, data on demographic variables, the number of patients reporting chest pain and other chest sensations at the onset of acute myocardial infarction and chest pain intensity, description, location and radiation across the chest were collected.

RESULTS

A total of 128 participants equally divided by gender were recruited. Chest pain was more prevalent among men than women (84.37% vs. 67.19%, p < 0.05). Although no statistical significance was found, Chinese men had higher mean chest pain intensity scores (7.54 SD 2.35 vs. 7.51 SD 2.25) and reported less atypical chest pain (0.00% vs. 9.3%) compared with women. Men had more upper right sided chest pain (40.74% vs. 20.93%, p = 0.038) whereas women experienced increased neck pain and pain to the upper central chest, middle central chest, upper central back, middle central back and middle right back regions.

CONCLUSIONS

Discreet gender differences in chest pain perceptions exist between Chinese men and women, with the latter group, who may be considered as a high-risk group for missed and delayed diagnosis from myocardial infarction, reporting more atypical presentations.

RELEVANCE TO CLINICAL PRACTICE

Irrespective of culture, women with myocardial infarction tend to present with atypical chest pain symptoms and therefore they should be aggressively investigated.

Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006

OBJECTIVES

This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain.

METHODS

A nationally representative ED data sample for all adults (>or=18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997-2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics.

RESULTS

Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51 to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered.

CONCLUSIONS

Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect "downstream" clinical care and help eliminate observed disparities in cardiac outcomes.

Racial differences in women's prodromal and acute symptoms of myocardial infarction

BACKGROUND

Minority women, especially black and Hispanic women, have higher rates of coronary heart disease and resulting disability and death than do white women. A lack of knowledge of minority women's symptoms of coronary heart disease may contribute to these disparities.

OBJECTIVE

To compare black, Hispanic, and white women's prodromal and acute symptoms of myocardial infarction.

METHODS

In total, 545 black, 539 white, and 186 Hispanic women without cognitive impairment at 15 sites were retrospectively surveyed by telephone after myocardial infarction. With general linear models and controls for cardiovascular risk factors, symptom severity and frequency were compared among racial groups. Logistic regression models were used to examine individual prodromal or acute symptoms by race, with adjustments for cardiovascular risk factors.

RESULTS

Among the women, 96% reported prodromal symptoms. Unusual fatigue (73%) and sleep disturbance (50%) were the most frequent. Eighteen symptoms differed significantly by race (P<.01); blacks reported higher frequencies of 10 symptoms than did Hispanics or whites. Thirty-six percent reported prodromal chest discomfort; Hispanics reported more pain/discomfort symptoms than did black or white women. Minority women reported more acute symptoms (P < .01). The most frequent symptom, regardless of race, was shortness of breath (63%); 22 symptoms differed by race (P <.01). In total, 28% of Hispanic, 38% of black, and 42% of white women reported no chest pain/discomfort.

CONCLUSIONS

Prodromal and acute symptoms of myocardial infarction differed significantly according to race. Racial descriptions of women's prodromal and acute symptoms should assist providers in interpreting women's symptoms.

Predictors of pre-hospital delay among patients with acute myocardial infarction

OBJECTIVE

To evaluate current literature on predictors of pre-hospital delay among patients with acute myocardial infarction (AMI).

METHODS

Medline, CINHAL, and Psych Info databases were searched using keywords: attitude to illness/health, health beliefs, help/health seeking behavior, health behavior, psychosocial factors, treatment delay, socioeconomic factors, time factors, pre-hospital delay, and symptoms. These keywords were combined with AMI to identify literature published during 1995-2008.

RESULTS

Twenty-six data-based research articles were identified. Delay varied across literature and median pre-hospital delay was often reported due to distribution skewness resulting from extremely prolonged values (1.5-15.2h). Six categories of predictors influenced pre-hospital delay; socio-demographic, symptom onset context, cognitive, affective/psychological, behavioral, and clinical factors. Pre-hospital delay was shortest when the decision to seek healthcare was facilitated by family members or coworkers and when symptoms suggestive of heart attack were continuous and severe.

CONCLUSION AND PRACTICE IMPLICATIONS

Developing interventions programs to reduce pre-hospital delay for high-risk patients is warranted. Because decision delay is the only modifiable part by intervention, it is recommended that future investigations and interventions attend to decision time as the primary variable of interest instead of combining it with transportation time. Moreover, content of patient education need to emphasize on symptom awareness and recognition, and prompt and proper patient actions for optimum results. Also, in order to eliminate sampling bias resulting from investigating surviving AMI patients, it is recommended that future studies incorporate data from both surviving and surrogates of non-surviving AMI patients.

Presentation of stable angina pectoris among women and South Asian people

BACKGROUND

There is speculation that women and South Asian people are more likely than men and white people to report atypical angina and that they are less likely to undergo invasive management of angina. We sought to determine whether atypical symptoms of angina pectoris in women and South Asians impacted clinically important outcomes and clinical management.

METHODS

We prospectively identified 2189 South Asian people and 5605 white people with recent-onset chest pain at 6 chest-pain clinics in the United Kingdom. We documented hospital admissions for acute coronary syndromes, coronary deaths as well as coronary angiography and revascularization procedures.

RESULTS

Atypical chest pain was reported by more women than men (56.5% vs 54.5%, p < 0.054) and by more South Asian patients than white patients (59.9% vs 52.5%, p < 0.001). Typical symptoms were associated with coronary death or acute coronary syndromes among women (hazard ratio [HR] 2.30, 95% CI 1.70-3.11, p < 0.001) but not among men (HR 1.23, 95% CI 0.96-1.57, p = 0.10). Typical symptoms were associated with coronary outcomes in both South Asian and white patients. Among those with typical symptoms, women (HR 0.76, 95% CI 0.63-0.92, p = 0.004) and South Asian patients (HR 0.52, 95% CI 0.41-0.67, p < 0.001) were less likely than men and white patients to receive angiography.

INTERPRETATION

Compared to those with atypical chest pain, women and South Asian patients with typical pain had worse clinical outcomes. However, sex and ethnic background did not explain differences in the use of invasive procedures.

Association between subjective descriptors of coronary pain and disease characteristics: A pilot study in a Hellenic rural population

PURPOSE

We explored whether the way Hellenic patients describe their cardiac chest pain (verbal descriptions of the nature, intensity, temporal quality, location and radiation) associates with the diagnosis [acute myocardial infarction (AMI) versus unstable angina (UA)] as well as with the location of the coronary lesions.

METHODS

A cross-sectional correlational design was employed to study 80 consecutive coronary care patients (44 with AMI, 36 with UA) from northwestern Hellas.

RESULTS

Pain intensity did not differ significantly between AMI and UA, in contrast to treatment-seeking behaviour and accompanying symptoms (p< or =0.03). Of AMI patients, women used more often the word "pain" (p=0.011), and indicated pain at the left shoulder (p=0.004). AMI patients used fewer words (p=0.03), and experienced pain at the back of the neck (p=0.03) and of the left arm (p=0.02) less often. The descriptions "knob", "constriction" and "drill" were more prevalent in UA patients (p<0.01). The description "drill" discriminated between diagnostic groups in a multivariate model (p=0.03). Associations between the infarct and pain location (p< or =0.03), and the use of some sensory descriptors (p< or =0.02) were detected. Pain locations associated with ECG findings (p< or =0.005).

CONCLUSIONS

Subjective acute coronary pain descriptions and pain characteristics may associate with the pathophysiological processes in coronary syndromes.

Racial differences in the use of respiratory medications in premature infants after discharge from the neonatal intensive care unit

OBJECTIVE

To determine the effect of race and ethnicity on the use of oral beta-agonists, inhaled beta-agonists, and inhaled corticosteroids to treat respiratory symptoms in former premature infants after controlling for medical conditions, socioeconomic status, and site of outpatient care.

STUDY DESIGN

Using a population cohort of infants born at a gestational age < or = 34 weeks at 5 Northern California Kaiser Permanente hospitals between 1998 and 2001 (n = 1436), we constructed multivariable models to determine predictive factors for the receipt of respiratory medications during the first year after discharge.

RESULTS

After controlling for confounding factors, black infants were more likely to receive oral beta-agonists compared with white infants (OR 4.30, 95% CI 2.33-7.94), and Hispanic infants were less likely to receive inhaled beta-agonists (OR 0.62, 95% CI 0.39-0.99) or inhaled corticosteroids (OR 0.28, 95% CI 0.12-0.67). These findings were not explained by more outpatient visits for respiratory symptoms in black or Hispanic infants, because the observed racial differences persisted when children of similar respiratory symptoms were examined.

CONCLUSIONS

Even in a high-risk population of insured infants, substantial racial differences persist in the use of respiratory medications that could not be explained by differences in respiratory symptoms.

Women's prehospital delay associated with myocardial infarction: does race really matter?

BACKGROUND/RESEARCH OBJECTIVE: Well-documented disparities in cardiovascular health account for approximately one third of the difference in life expectancy between blacks and whites. Mortality from cardiovascular disease is greater among black women than among white women, and black women report longer delays in treatment seeking following onset of symptoms of acute myocardial infarction (AMI). Despite this disparate burden, there is little race-specific data on correlates of delay for black or white women. This secondary data analysis compares duration and correlates of delay in treatment seeking by race following onset of AMI symptoms.

SUBJECTS/METHODS

We analyzed self-report data from 509 black and 500 white women, interviewed 4 to 6 months after AMI, using multivariable logistic and linear regression.

RESULTS/CONCLUSIONS

Median delay time was nonsignificantly shorter for black than for white women (1.0 vs 1.5 hours). Equal proportions of black and white women (57% vs 54%) sought treatment within 2 hours of symptom onset. In multivariable analyses, correct attribution of symptoms to AMI was a significant predictor of treatment seeking within 2 hours of symptom onset for black and white women (odds ratios = 2.79 and 3.86, respectively); eligibility for public insurance was a significant predictor for black women only (odds ratio = 2.3). Common comorbidities, AMI risk factors, and other demographics were not significantly associated with delay time. Insurance coverage and the correct attribution of symptoms to cardiac causes are substantial and modifiable predictors of delay in seeking treatment of AMI.

Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Ethnic differences in the timely diagnosis of children with Type 1 diabetes mellitus in the Netherlands: clinical presentation at onset

AIMS

Little is known about ethnic differences in the timely diagnosis of Type 1 diabetes mellitus (Type 1 DM). This study aimed to assess ethnic inequalities in the timely diagnosis of Type 1 DM, as indicated by a more adverse clinical condition at onset. In addition, we assessed whether these differences could be explained by differences in socio-economic status.

METHODS

From a national register, we selected 3128 children aged < 15 years with newly diagnosed Type 1 DM. Ethnic differences in serum glucose, blood pH, bicarbonate, presence of ketonuria, level of consciousness, hydration status,and diabetic ketoacidosis were assessed by logistic regression. A measure of socioeconomic status based on postal codes was used as an explanatory variable.

RESULTS

The risk of adverse clinical presentation was 1.5-2 times higher in non-Western immigrants than Dutch children, while Western immigrant children did not differ from Dutch children. Blood pH, bicarbonate level, and level of consciousness were lower in Turkish and Antillean children in particular. The adverse socio-economic position of immigrant children contributed very little to these differences in clinical presentation.

CONCLUSIONS

Non-Western children were likely to be sicker at first presentation of Type 1 DM, and thus diagnosis may have been delayed. These disparities were not accounted for by differences in socio-economic status. Possible explanations may be difficulties in recognition of symptoms, failure of GPs to take symptom reporting seriously and lack of awareness of the fact that Type 1 DM occurs more often in certain ethnic groups.

Symptom expression in coronary heart disease and revascularization recommendations for black and white patients

OBJECTIVES

We examined whether symptoms of coronary heart disease vary between Black and White patients with coronary heart disease, whether presenting symptoms affect physicians' revascularization recommendations, and whether the effect of symptoms upon recommendations differs in Black and White patients.

METHODS

We interviewed Black and White patients in Pittsburgh in 1997 to 1999 who were undergoing elective coronary catheterization. We interviewed them regarding their symptoms, and we interviewed their cardiologist decision-makers regarding revascularization recommendations. We obtained coronary catheterization results by chart review.

RESULTS

Black and White patients (N=1196; 9.7% Black) expressed similar prevalence of chest pain, angina equivalent, fatigue, and other symptoms, but Black patients had more shortness of breath (87% vs 72%, P=.001). When we considered only those patients with significant stenosis (n=737, 7.1% Black) and controlled for race, age, gender, and number of stenotic vessels, those who expressed shortness of breath were less likely to be recommended for revascularization (odds ratio=0.535; 95% confidence interval=0.375, 0.762; P<.001), but there was no significant interaction with race.

CONCLUSIONS

Black patients reported shortness of breath more frequently than did White subjects. Shortness of breath was a negative predictor for revascularization for all patients with significant stenosis, but there was no difference in the recommendations by symptom by race.

Role of clinical presentation in diagnosing reflux-related non-cardiac chest pain

INTRODUCTION

Non-cardiac chest pain (NCCP) presents as a frequent diagnostic challenge, with patients tending to use a disproportionate level of health-care resources. Gastroesophageal reflux disease (GERD) is the most frequent cause of NCCP. Thus the typical symptoms of reflux, such as heartburn and regurgitation, when present as predominant symptoms are quite specific for diagnosing GERD but in patients with NCCP the clinical diagnosis of reflux is difficult, and invasive methods or the omeprazole test are required for its detection. The aim of the present study was to evaluate the role of clinical presentation when diagnosing GERD among patients with NCCP.

METHODS

Patients with NCCP underwent upper endoscopy, Bernstein and omeprazole tests. The patients were divided into two groups based on GER- or non-GER-related chest pain, and clinical presentation was compared between these two groups. Gastroesophageal reflux disease was considered positive when at least two methods were positive.

RESULTS

From 78 NCCP patients (41 male; mean age 50.4 +/- 2.3 years), the chest pain was related to GERD in 35 patients (44.8%). The two groups were the same based on sex and age. The chest pain severity, site, radiation and relation to food, exercise, and sleep were equal in the two groups, except for two symptoms: pain that was relieved by antacid (P < 0.031) and presence of classical reflux symptoms (P < 0.009), seen in the GERD patients. With regard to recent patient history, heartburn and regurgitation symptoms were seen more frequently in GERD patients (P < 0.036 and P < 0.002, respectively).

DISCUSSION

Clinical presentation is important in diagnosing GERD in NCCP. Although the chest pain is the same in reflux- and non-reflux-related NCCP, the symptoms of heartburn or regurgitation in the present or recent patient history are diagnostic for GERD-related chest pain.

Symptom perception: a concept exploration

The topic of this paper is a concept analysis of symptom perception using the theoretical phase of the Schwartz-Barcott Hybrid Model. The purpose of this paper is to explore symptom perception and related concepts and formulate a working definition. Sources of information include symptom perception and related concepts models and studies using the concepts as well as sources pertaining to related measurement tools. The conclusion of this exploration reveals several overlapping concepts. These concepts are synthesized into a working definition of symptom perception.

The influence of race and gender on time to initial electrocardiogram for patients with chest pain

OBJECTIVES

To determine whether race or gender affected time to initial electrocardiogram (ECG) for patients who presented to an emergency department with chest pain.

METHODS

This was a prospective cohort study of patients with chest pain. Patients were divided into three groups based on final diagnosis of acute myocardial infarction or unstable angina and all others with noncardiac chest pain. Data were analyzed using ranks in a two-way analysis of covariance adjusted for age.

RESULTS

A total of 4,358 patients were studied; 58.6% were women and 41.4% men, and 70.3% were African American, 26.0% white, and 3.6% other. Overall, nonwhite patients had longer times to initial ECG compared with white patients. These effects were consistent regardless of ultimate diagnosis. Overall, women had longer times to initial ECG than men. However, ECG time differed by final diagnosis. There were no differences in time to ECG for women compared with men with acute myocardial infarction or unstable angina, but women received an ECG significantly slower than men for noncardiac chest pain.

CONCLUSIONS

The first screening test for acute coronary syndrome, the ECG, took longer to obtain for nonwhite patients, regardless of final diagnosis. This was unfortunately consistent with the literature that shows racial disparities in all aspects of emergent cardiac care. For women, the overall delay in ECG time can be explained by delays for those women with noncardiac chest pain.

Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies

Despite a dramatic decline in mortality over the past three decades, coronary heart disease is the leading cause of death and disability in the U.S. Importantly, recent advances in the field of cardiovascular medicine have not led to significant declines in case fatality rates for women when compared to the dramatic declines realized for men. The current review highlights gender-specific issues in ischemic heart disease presentation, evaluation, and outcomes with a special focus on the results published from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. We will present recent evidence on traditional and novel risk markers (e.g., high sensitivity C-reactive protein) as well as gender-specific differences in symptoms and diagnostic approaches. An overview of currently available diagnostic test evidence (including exercise electrocardiography and stress echocardiography and single-photon emission computed tomographic imaging) in symptomatic women will be presented as well as data using innovative imaging techniques such as magnetic resonance subendocardial perfusion, and spectroscopic imaging will also be discussed.

Womenʼs Delay in Seeking Treatment With Myocardial Infarction

Women, especially those older than 65 years, delay longer than do men before seeking medical treatment for symptoms of an acute myocardial infarction (AMI). The majority of delay time results from the patient's lengthy decision-making processes after symptoms begin and before seeking medical treatment. Effective treatment is time dependent as mortality and morbidity rise with each hour of delay. Therefore, the purpose of this research was 2-fold: (1) to synthesize reported research findings concerning women's reasons for delay in seeking treatment for symptoms of an AMI and (2) to identify areas for further research. Using Cooper's (Synthesizing Research. 3rd ed. London: Sage; 1998) framework for integrative review, this manuscript synthesized the literature from 48 reports published from 1995 to 2003 to describe the primary reason(s) for women's prehospital delay. Three categories emerged to explain why women delay in seeking treatment: (1) clinical, (2) sociodemographic, and (3) psychosocial factors. These factors are found to be multifaceted and complex. The most significant reasons for delay in seeking treatment for symptoms of AMI are the following: atypical presentation of symptoms, severity of presenting symptoms, presence of other chronic illnesses that confused acute symptoms, correct attribution or labeling of symptoms to the heart, perceived seriousness of the symptoms, beliefs of low self-perceived vulnerability to heart attack, and engagement in various other coping mechanisms. This synthesis identified and clarified the current state of science regarding women's prehospital delay in seeking treatment for symptoms of an AMI. Areas for future research are also discussed.

Public recognition of major signs and symptoms of heart attack: seventeen states and the US Virgin Islands, 2001

BACKGROUND

Timely access to emergency cardiac care and survival is partly dependent on early recognition of heart attack symptoms and immediate action by calling emergency services. We assessed public recognition of major heart attack symptoms and knowledge to call 9-1-1 for an acute event.

METHODS

Data are from the 2001 Behavioral Risk Factor Surveillance System, a state-based telephone survey. Participants (n = 61,018) in 17 states and the U.S. Virgin Islands indicated whether the following were heart attack symptoms: pain or discomfort in the jaw, neck, back; feeling weak, lightheaded, faint; chest pain or discomfort; sudden trouble seeing in 1 or both eyes (false symptom); pain or discomfort in the arms or shoulder; shortness of breath. Participants also indicated their first action if someone was having a heart attack.

RESULTS

Most persons (95%) recognized chest pain as a heart attack symptom. However, only 11% correctly classified all symptoms and knew to call 9-1-1 when someone was having a heart attack. Symptom recognition and the need to call 9-1-1 was lower among men than women, persons of various ethnic groups than whites, younger and older persons than middle-aged persons, and persons with less education. Persons with high blood pressure, high cholesterol, diabetes mellitus, or prior heart attack or stroke were not appreciably more likely to recognize heart attack symptoms than were persons without these conditions.

CONCLUSIONS

Public health efforts are needed to increase recognition of the major heart attack symptoms in both the general public and groups at high risk for an acute event.